Chapter 5: Radiographic Assessment · a normal neurological examination, is without an injury...
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Chapter 5: Radiographic Assessment �
(2013) 72 (suppl_3): 54-72. DOI: https://doi-org.offcampus.lib.washington.e-du/10.1227/NEU.0b013e318276edeePublished: 01 March 2013
Timothy C. Ryken, MD, MS; Mark N. Hadley, MD � � ; Beverly C. Walters, MD, MSc, FRCSC;Bizhan Aarabi, MD, FRCSC; Sanjay S. Dhall, MD; Daniel E. Gelb, MD;R. John Hurlbert, MD, PhD, FRCSC; Curtis J. Rozzelle, MD; Nicholas Theodore, MD
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Keywords: Asymptomatic trauma patient, Cervical spinal trauma, Obtunded/unevaluabletrauma patient, Radiographic assessment, Symptomatic trauma patient
Topic: magnetic resonance imaging , diagnostic radiologic examination , spinal injuries ,
wounds and injuries , diagnostic imaging , stupor , cervical spine
Issue Section: Article
RECOMMENDATIONS
Awake, Asymptomatic Patient
� �
Level 1
In the awake, asymptomatic patient who is without neck pain or tenderness, who has
a normal neurological examination, is without an injury detracting from an accurate
evaluation, and who is able to complete a functional range of motion examination;
radiographic evaluation of the cervical spine is not recommended.
Discontinuance of cervical immobilization for these patients is recommended
without cervical spinal imaging.
Awake, Symptomatic Patient
Level I
In the awake, symptomatic patient, high-quality computed tomography (CT)
imaging of the cervical spine is recommended.
If high-quality CT imaging is available, routine 3-view cervical spine radiographs
are not recommended.
If high-quality CT imaging is not available, a 3-view cervical spine series
(anteroposterior, lateral, and odontoid views) is recommended. This should be
supplemented with CT (when it becomes available) if necessary to further define
areas that are suspicious or not well visualized on the plain cervical x-rays.
Level III
In the awake patient with neck pain or tenderness and normal high-quality CT
imaging or normal 3-view cervical spine series (with supplemental CT if indicated),
the following recommendations should be considered:
1. Continue cervical immobilization until asymptomatic,
2. Discontinue cervical immobilization following normal and adequate dynamic
flexion/extension radiographs,
3. Discontinue cervical immobilization following a normal magnetic resonance
imaging (MRI) obtained within 48 hours of injury (limited and conflicting Class II
and Class III medical evidence), or,
4. Discontinue cervical immobilization at the discretion of the treating physician.
Obtunded or Unevaluable Patient
Level I
In the obtunded or unevaluable patient, high-quality CT imaging is recommended as
the initial imaging modality of choice. If CT imaging is available, routine 3-view
cervical spine radiographs are not recommended.
If high-quality CT imaging is not available, a 3-view cervical spine series
(anteroposterior, lateral, and odontoid views) is recommended. This should be
supplemented with CT (when it becomes available) if necessary to further define
areas that are suspicious or not well visualized on the plain cervical x-rays.
Level II
In patients in whom there is a high clinical suspicion of injury yet have a normal
high-quality CT imaging study, it is recommended that the decisions for further
patient management involve physicians trained in the diagnosis and management of
spinal injuries.
Level III
In the obtunded or unevaluable patient with a normal high-quality CT or normal 3-
view cervical spine series, the following recommendations should be considered:
1. Continue cervical immobilization until asymptomatic,
2. Discontinue cervical immobilization following a normal MRI study obtained
within 48 hours of injury, (limited and conflicting Class II and Class III medical
evidence), or,
3. Discontinue cervical immobilization at the discretion of the treating physician.
In the obtunded or unevaluable patient with a normal high-quality CT, the routine
use of dynamic imaging appears to be of marginal benefit and is not recommended.
RATIONALE
Spinal cord injury is a potentially devastating consequence of acute trauma and can
occur with/be exacerbated by improper immobilization of an unstable cervical spinal
injury. Immobilization of an injury victim's cervical spine following trauma is a
universal standard practiced by Emergency Medical Services systems and is now based
on pre-hospital clinical criteria. Immobilization of the potentially injured cervical spine
is maintained until spinal column injury is ruled out by clinical assessment and/or
radiographic survey. Radiographic study of the cervical spine of every trauma patient is
costly and results in significant radiation exposure to a large number of patients, very
few of whom will have a spinal column injury. Asymptomatic trauma patients, defined
by rigid clinical criteria, require no radiographic assessment irrespective of the
mechanism of potential injury.
Trauma patients who are symptomatic, that is complain of neck pain, have cervical
spine tenderness, have symptoms or signs of a neurological deficit associated with the
cervical spine, and trauma patients who cannot be assessed for symptoms or signs
(those who are unconscious, uncooperative or incoherent, intoxicated, or who have
associated traumatic injuries that distract from their assessment) require radiographic
study of the cervical spine prior to the discontinuation of cervical spine immobilization.
Many investigators have proposed strategies and imaging techniques to accomplish x-
ray clearance of the cervical spine after trauma, particularly in the symptomatic or the
obtunded patient.
In 2002, the guidelines author group of the Joint Section on Disorders of the Spine of
the American Association of Neurological Surgeons (AANS) and the Congress of
Neurological Surgeons(CNS) published 2 medical evidence-based guidelines on the
topic of imaging the cervical spine following acute blunt trauma entitled,
“Radiographic Assessment of the Cervical Spine in Asymptomatic Trauma Patients”
and “Radiographic Assessment of the Cervical Spine in Symptomatic Trauma
Patients.” The purpose of the current review is to build on that foundation, adding
pertinent new evidence on these issues generated over the past decade.
SEARCH CRITERIA
A computerized search of the database of the National Library of Medicine (PubMed)
between 1966 and 2011 was conducted using the search terms “spinal cord injury” or
“spinal fractures” or “spinal injuries” and resulted in 30 238 references. A similar
search was conducted with search terms “clearance” or “diagnosis” or “radiographs”
that provided 23 005 577 citations. Combining these 2 searches using “and” gave 6399
references. The search was limited to the English language and human subjects. This
resulted in 4942 citations. The titles and abstracts of these references were reviewed.
Studies that investigated the diagnostic potential of an imaging technique to assess
cervical trauma were selected. Additional articles were obtained from the bibliographies
of selected manuscripts. Thirty-two manuscripts were identified that provided either
direct or supporting medical evidence on the diagnostic potential of cervical spinal
imaging modalities. In general, priority was given to large (greater than 100 patients)
prospective studies, meta-analyses, and articles published since the previous iteration
of this guideline. Fifteen articles addressing cervical spinal imaging in asymptomatic
trauma patients, 25 references addressing imaging in symptomatic patients, and 20
references addressing imaging in the obtunded patient are summarized in Evidentiary
Table format (Tables 3–5).
SCIENTIFIC FOUNDATION
In 2002, the guidelines author group of the Joint Section on Disorders of the Spine and
Peripheral Nerves of the American Association of Neurological Surgeons and the
Congress of Neurological Surgeons published 2 medical evidence-based guidelines on
the topic of radiographic assessment of the cervical spine following acute trauma.
Based on 8 Class I medical evidence studies, diagnostic standards (Level I) were
1–2
1,2
recommended at a high level of medical certainty that for asymptomatic patients, the
“Radiographic assessment of the cervical spine is not recommended for trauma
patients who are awake, alert, and not intoxicated, who are without neck pain or
tenderness, and who do not have significant associated injuries that detract from their
general evaluation.” For all other patients (symptomatic) medical evidence-based
diagnostic standards (Level I) recommendations were offered: “A 3-view cervical spine
series (AP, lateral, and odontoid views) is recommended for the radiographic
evaluation of the cervical spine in patients who are symptomatic after traumatic injury.
This should be supplemented with CT to further define areas that are suspicious or not
well visualized on the plain cervical x-rays.” Further, option or Level III
recommendations based on Class III medical evidence were offered suggesting that
“cervical spine immobilization in awake patients with neck pain or tenderness and
normal cervical spine x-rays (including supplemental CT as necessary) be discontinued
after either, (1) normal and adequate dynamic flexion/extension radiographs, or (2) a
normal MRI study obtained within 48 hours of injury. For obtunded patients, Class III
medical evidence supported the recommendation that “Cervical spine immobilization
in obtunded patients with normal cervical spine x-rays (including supplemental CT as
necessary) may be discontinued (1) after dynamic flexion/extension studies performed
under fluoroscopic guidance, (2) after a normal MRI study is obtained within 48 hours
of injury, or (3) at the discretion of the treating physician.” These 3 clinical scenarios
following trauma (asymptomatic, symptomatic, and the obtunded patient) are the
focus of this update on the medical evidence on this important topic.
In 2009, the Eastern Association for the Surgery of Trauma (EAST) published an
updated medical evidence review on the identification of cervical spinal injuries
following trauma. The authors utilize a 3-tiered system of medical evidence and linked
their recommendations to the quality of the medical evidence reported in the world's
literature. Fifty-two articles were selected for inclusion. The EAST author group
concluded that Class I medical evidence indicates CT has become superior to plain
radiography as the primary imaging modality of the cervical spine for acute trauma
patients who required cervical imaging. A detailed review of the updated EAST
recommendations suggest that the methodology used by the EAST author group is
better suited to assess a therapeutic intervention, rather than to evaluate the validity
and accuracy of a diagnostic test, which requires a different set of medical evidence
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4,5
criteria. The current effort to update the medical evidence of these 2 guidelines
consider radiographic imaging of the cervical spine in acute trauma patients to be a
diagnostic test. Appropriate, distinct, and specific medical evidence grading criteria for
a diagnostic test have been applied.
Since the original evidence-based medicine guideline produced on the issue of
radiographic assessment of the asymptomatic patient in 2002, four clinical studies and
a recent meta-analysis have been published. These citations provide Class I and Class II
medical evidence in support of the original Level I recommendation that truly
asymptomatic patients require no cervical spinal imaging after trauma.
In 2001, Stiell et al published a study of 8924 awake blunt trauma patients treated in
10 large Canadian medical centers. The investigators evaluated 20 different
standardized clinical findings in an attempt to create a valid decision-making rule
sensitive for detecting acute cervical spinal injuries, therefore allowing the selective
use of radiography in alert trauma patients. The reported incidence of a significant
cervical spinal injury was 1.7%. The resultant Canadian C-Spine Rule (CCR) utilizes 3
questions: (1) presence of a high-risk factor that mandates radiography (ie: age 65
years or older, dangerous mechanism of injury, or paresthesias in extremities), (2)
presence of a low-risk factor allowing safe assessment of range of motion (ie: simple
rear-end motor vehicle collision, sitting position in ED, ambulatory at any time
following injury, delayed onset of neck pain, or absence of midline C-spine
tenderness), and (3) ability to actively rotate neck 45° to the left and right. Use of the
CCR resulted in 100% sensitivity for a significant cervical spinal injury, (95%
confidence interval [CI], 98%-100%) and 42.5% specificity (95% CI, 40%-44%).
The largest series referenced in the previous version of this guideline was published by
Hoffman et al in 2000 and generated decision-making rules subsequently referred to
as the NEXUS (National Emergency X-Radiography Utilization Study Group) criteria.
This study involved the prospective study of 34 069 blunt trauma patients of which
4309 were asymptomatic. All patients underwent standard 3 view cervical spinal
radiographs supplemented with CT as needed. Five criteria had to be met in order to be
classified as having a low probability of injury: no midline cervical tenderness, no focal
neurologic deficit, normal alertness, no intoxication, and no painful, distracting injury.
These criteria correctly identified 810 of the 818 patients who had a cervical spinal
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injury (true positives), resulting in a sensitivity of 99.0%, a specificity of 12.9%, a
negative predictive value (NPV) of 99.8% and a positive predictive value (PPV) of 2.7%.
Only 2 patients were misclassified as unlikely to have an injury and had a clinically
significant injury (false negatives) for a calculated sensitivity of 99.6%, a specificity of
12.9%, a NPV of 99.9% and a PPV of 1.9%. Only 1 of these 2 patients required surgical
treatment for a C6 laminar fracture with delayed onset paresthesias. The other missed
injury required no treatment.
In 2003, Stiell et al conducted a prospective cohort study comparing the Canadian C-
spine rule (CCR) vs the NEXUS criteria. Three hundred and ninety-four physicians
evaluated 8283 patients prior to radiographic imaging, 169 of which had clinically
significant cervical spinal injuries (2%). Application of the CCR resulted in 1 missed
patient injury. Use of the NEXUS low risk criteria (NLC) resulted in 16 missed cervical
spinal injuries, 4 of which were unstable. In this Class I medical evidence study, Stiell et
al found the CCR was statistically significantly more sensitive than the NEXUS criteria
in the detection of a significant cervical spinal injury. Of interest, the application of the
CCR rather than the NEXUS criteria would have resulted in significantly lower
radiography rates (55.9% vs 66.6%, P < .001, see Table 1).
Table 1
Comparison of Canadian C-Spine Rule With the National Emergency X-Radiography Study Group Criteria forLow-Risk Criteria
Table 2
Detection of Cervical Spinal Injury Following Blunt Trauma
In 2010, Anderson et al produced a meta-analysis of 14 Class I medical evidence
studies published between 1966 and 2004. The authors' inclusion criteria were:
(1) a prospectively applied protocol; (2) reported outcomes to allow calculation of
sensitivity, specificity, NPV, and PPV; and (3) follow-up to determine the status of
potential missed injuries with minimum of a 2-week telephone call or a follow-up CT
scan. The 3 senior authors each independently confirmed the validity of the included
articles and independently verified each publication's analysis as well as extraction of
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6–8,10–20
true-positive, true-negative, false-positive, and false-negative numbers. Original scale
and log odds meta-analysis were performed. Sensitivity, specificity, PPV, and NPV were
calculated using random effects methodology. The 14 studies that met these rigid
inclusion criteria correctly identified the 3.7% of alert trauma patients who had
confirmed cervical spinal injuries (PPV, 3.7%). They missed the 0.2% of patients who
had acute injuries who should have had cervical radiography performed (NPV, 99.8%).
The random effects model used in the meta-analysis resulted in a collective sensitivity
of 0.981 (98.1%) and a specificity of 0.354. The authors concluded that the alert,
asymptomatic patient without a neurologic deficit who can complete a functional
range-of-motion examination and is free from other major distracting injury may
safely be released from cervical spine immobilization without radiographic evaluation,
with a sensitivity of 98.1% and a NPV of 99.8%. Additional supporting data is provided
in Table 3.
Table 3
Evidentiary Table: Radiographic Assessment: Asymptomatic
Table 4
Evidentiary Table: Radiographic Assessment: Symptomatic
Table 5
Evidentiary Table: Radiographic Assessment: Obtunded
Awake Symptomatic Patient
In the previously produced 2002 guideline on the topic of Radiographic Assessment of
the Symptomatic Patient, the author group concluded that a 3-view cervical spine
series (AP, lateral, and odontoid views) was recommended for radiographic evaluation
of the cervical spine in patients who are symptomatic after traumatic injury (Standard
or Level I recommendation based on Class I medical evidence). Class I medical evidence
suggests that those studies should be supplemented with CT as necessary, to define
areas that are suspicious or not well-visualized on the plain cervical x-rays. These
recommendations were based in part on a series of high quality articles considered to
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a
a
a
provide Class I medical evidence for diagnostic testing. The combined series of Berne et
al, Ajani et al, Davis et al, and MacDonald et al included 1049 trauma patients
evaluated with 3-film radiography. The sensitivity of the 3-film technique for fracture
detection in these series ranged from 60% to 84%. The NPV ranged from 85% to 98%,
increasing to 100% with the addition of dynamic studies. The current update on the
topic of radiographic assessment of the symptomatic patient following acute trauma
will focus on the increasing reliance on CT rather than plain radiography to assess the
cervical spine (see Table 2 for comparison).
In 2005, Holmes and Akkinepalli published a meta-analysis of studies comparing CT
and plain radiographs in detecting cervical spinal injuries in patients predetermined to
require imaging by clinical criteria. The authors included 7 studies, including 5 graded
to provide Class III medical evidence and 2 to provide Class IV medical evidence on a 4-
tiered evidence grading scale. They failed to utilize an appropriate assessment
scheme for a diagnostic test, and instead attempted to find randomized studies to
provide Class I medical evidence. They did prioritize prospective data collection, an
adequate study population, and the use of gold standards. The pooled sensitivity of
plain radiographs for detecting cervical spinal injury in their analysis was 54%
compared to 98% for CT. This study provides supporting Class III medical evidence that
CT may be superior to plain radiographs to detect cervical spinal injury following
trauma.
In 2009, Bailitz et al published a prospective, comparative study of cervical spine
radiographs (CSR) with cervical CT (CCT) to detect cervical spinal injury after trauma.
The study assessed awake adult patients who had sustained blunt trauma who met 1 or
more of the NEXUS criteria for spinal assessment following acute trauma. Three-view
CSR and CCT were obtained in a standard protocol. Each CSR and CCT study was
interpreted independently by a different blinded radiologist. Clinically significant
injuries were defined as those requiring 1 or more of the following interventions:
operative procedure, halo application, and/or rigid cervical collar. The entire data set
included 1583 patients, but 78 patients (4.9%) were excluded due to lack of complete
studies. The remaining 1505 patient data set contained 78 with a cervical spinal injury
determined by 1 or both radiographic assessment methods. The sensitivity of CCT was
100% compared to 36% for CSR. The authors conclude that CT is significantly superior
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to plain film radiography for the initial evaluation of cervical spinal injuries following
trauma and should be the imaging modality of choice. Their study provides Class I
medical evidence for a diagnostic test.
In 2007, Mathen et al published a prospective Class I medical evidence study of 667
acute trauma patients including 60 patients with cervical spine injuries (9% of total) all
evaluated with both cervical spine films and CT. CT had a sensitivity of 100% and a
specificity of 99.5%. Plain films had a sensitivity of 45% and a specificity of 97.4%.
Plain films missed 15 of 27 clinically significant cervical spinal injuries (55.5%). The
authors concluded that CT is superior to plain spine films in the acute setting, and that
plain films add no significant information to a high quality CT.
Griffen et al in 2003 studied a series of 1199 acute trauma patients at risk for a cervical
spinal injury who had both plain films and CT studies. There were 116 cervical spine
injuries detected. All were identified by CT (sensitivity = 1.00, 100%; NPV = 1.00). Plain
radiographs detected only 75 of the injuries (sensitivity = 0.64, 64%; NPV = 0.96). The
authors summarized previous published studies comparing the sensitivity of CT to the
sensitivity of plain films to detect cervical injury after blunt trauma.
Combining the patients from these series resulted in a total patient population of 3034.
Ten percent were found to have cervical spinal injuries (309). The combined sensitivity
of plain films was 53%. The combined sensitivity of CT was of 98%. This study and
review provides Class I medical evidence on the superiority of CT for the assessment of
cervical spinal injuries after trauma.
In 2001, Schenarts et al published a large prospective series evaluating the role of
cervical CT in their blunt trauma population. They reported on 2690 consecutive blunt
trauma admissions. They applied the EAST recommendations to determine which
patients should be studied radiographically to assess for potential cervical spinal
injuries. This latter group consisted of 1356 patients who had experienced blunt
trauma, many of whom were going to have CT studies performed on other body regions
(ie, head injury, abdominal injury). All were assessed with 5-view cervical spine x-rays.
There were 70 cervical spine injuries detected (incidence 5.2%). CT detected 67 of the
70 injuries (sensitivity 96%). Five-view plain films detected 38 of the 70 injuries
(sensitivity 54%). The authors concluded that the use of the EAST guidelines for
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clearance of the cervical spine correctly identified all injuries in their study population.
They found CT was superior to plain films in the evaluation of acute cervical trauma.
Daffner et al published a retrospective analysis of 5172 trauma admissions and
identified 297 cervical fractures (5.4%). Of these, 245 were identified to have had both
plain films and CT performed. CT identified 243 of the 245 fractures (sensitivity 0.992,
99.2%). Comparatively, plain films identified only 108 fractures (sensitivity 0.441,
44.1%). Their 2006 study is considered to provide Class III medical evidence due to the
loss of subjects (17.5%) and its retrospective nature. Of note is that the 2 fractures
missed on CT were readily identified on plain films. The authors recommended that
lateral plain films be included with CT to assess for cervical spinal injury after trauma.
Both fractures missed by CT involved the C2 spinous process; 1 was obscured by dental
work and the other was in the plane of the scan. The Daffner et al study highlights the
need for ensuring that the cervical imaging utilized to assess the cervical spine
adequately visualizes the region of interest, regardless of the specific imaging modality
employed, but fails to provide medical evidence for the utility of plain films to
supplement CT in this setting.
In addition to CTs superior sensitivity in fracture detection, authors have reported on
other advantages of CT over plain radiography in the acute trauma setting. Daffner et
al published a series of studies evaluating the efficiency of plain radiographs
compared to CT, and found that the average time involved to obtain a cervical CT scan
was 11 to 12 minutes, approximately half the time required to obtain a full radiographic
series of the cervical spine. Blackmore et al performed a cost-effectiveness analysis
for high risk subjects and concluded that the higher short-term cost of CT would be
offset by the increased sensitivity of CT for fracture detection, the shortened time
required for the evaluation, and a decreased need for additional imaging.
Symptomatic Patient With Negative Initial Imaging.
The author group of the previous guideline published on this topic in 2002
recommended that cervical spinal immobilization could be discontinued in the awake
but symptomatic patient with normal radiographic studies supplemented by thin
section CT as indicated, following either normal flexion and extension radiographs or a
normal MRI obtained within 48 hours of injury. Based on Class III medical evidence,
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the NPV of normal 3-view plain films supplemented with flexion and extension x-rays
ranged from 93% to 100%, and the NPV of an MRI obtained within 48 hours of
injury ranged from 90% to 100%. Several studies evaluating cervical MRI in the acute
trauma setting suggested that no significant injuries occurred in the setting of a
normal MRI. Isolated cases in which significant injuries were not detected by
MRI have raised concerns and prompted additional study.
Studies published since the previous guidelines have focused on the role of dynamic
imaging and/or MRI in assessment of symptomatic trauma patients with negative
initial radiographs or CT imaging, in an attempt to define which patients require
continued spinal immobilization. The studies are varied in their comparison groups and
in the level of medical evidence they provide. The report by Duane et al provides Class
II medical evidence that MRI is significantly more sensitive than dynamic films, but the
Class III medical evidence study by Schuster et al concludes that the routine use of
MRI is of minimal benefit in detecting additional injury. Class II evidence published by
Pollack et al and Class III medical evidence offered by Insko et al indicate that
dynamic films are of limited benefit in detecting additional injuries when the clinical
exam and CT imaging are normal.
In 2010, Duane et al published the only investigation to date directly comparing
dynamic imaging to MRI in this patient population. Their study evaluated 22 929
trauma patients, among whom 271 patients were studied with dynamic imaging, 49 of
whom were also assessed with MRI. MRI identified 8 patients with ligamentous injury.
Flexion and extension radiographs failed to identify any of the 8 ligamentous injuries
identified on MRI. When comparing dynamic studies to MRI (these authors considered
MRI to be the gold standard for ligamentous injuries), the sensitivity of dynamic films
was 0.0%, the specificity was 98%, the PPV was 0%, and the NPV was 83%. Flexion and
extension studies were incomplete in over 20.5% of the patients and ambiguous in
another 9.2%. The authors concluded that due to the often incomplete or ambiguous
results with dynamic imaging and the inability of flexion and extension radiographs to
identify many potential ligamentous injuries, MRI be used in the relatively infrequent
situation of a suspected cervical spinal ligamentous injury following trauma when the
initial radiographs or CT images did not identify a fracture injury. This study offers a
select few patients for comparison. The choice of MRI as the “gold standard” for
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ligamentous injury likely leads to a false endpoint. MRI has not been proven to
represent the gold standard for ligamentous injury in the literature, and is associated
with a high number of false-positive findings.
In 2005, Schuster et al reported a prospective study examining the role of MRI in
excluding significant injury in the symptomatic patient with a normal motor exam and
a normal CT evaluation of the cervical spine following acute trauma. The study
population included 2854 patients. Ninety-three patients had a normal admission
motor examination yet persistent cervical spine pain. All underwent MRI examination
and all were negative for a clinically significant injury. Seventeen patients had MRI
studies that revealed pre-existing degenerative cervical spondylosis, and 6 had spinal
canal stenosis secondary to ossification. The authors concluded that patients with a
normal motor exam and normal CT of the cervical spine do not require MRI imaging in
order to exclude a significant cervical spinal injury. The Class II medical evidence
offered in this publication is in conflict with the Class II medical evidence provided by
Duane et al in 2010.
Pollack et al reported a large multicenter prospective study evaluating the role of
dynamic plain films to supplement the standard 3-view radiographic evaluation of the
cervical spine in the acute trauma setting. Twenty-one centers participating in the
NEXUS project entered patients who had standard 3-view radiographs, as well as any
other imaging deemed necessary by their physicians. Eight hundred and eighteen
patients were diagnosed with a cervical spinal injury, of which 86 (10.5%) underwent
dynamic imaging. Two patients (2.3%) had injuries detected only on dynamic imaging.
The authors concluded that dynamic imaging added little to the acute evaluation of
patients suspected to have sustained cervical spinal trauma. This study provides Class
II medical evidence on this topic.
In 2002 Insko et al published a retrospective review of 106 consecutive trauma
patients in whom flexion and extension radiographs were obtained in the acute trauma
setting. Nine patients were identified who had cervical spinal injuries. Only 74 patients
(70%) had a range of flexion and extension felt to be adequate for diagnostic purposes.
Five of the 74 patients with acceptable range of motion had cervical spinal injuries
(6.75%). There were no missed ligamentous injuries in this group. Thirty-two of the
flexion and extension examinations (30%) were inadequate because of limited motion.
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Four of the 32 patients with inadequate range of motion on dynamic x-rays were
diagnosed with a significant injury either by CT or MRI (12.5%). The authors stressed
the need for adequate and complete dynamic studies if they are to be used for
diagnostic purposes. If adequate range of motion is not possible, they suggest MRI
should be considered to assess for ligamentous injury.
Sanchez et al instituted a single institution protocol to assess and image patients as
indicated following trauma. They performed cervical helical CT imaging on patients
who could not be cleared clinically. Patients with a neurological deficit underwent MRI,
but patients with no focal deficit and a normal CT scan were cleared. Prospective data
were collected on 2854 trauma patients. One hundred patients had cervical spine or
spinal cord injuries, of which 99 were identified by their sequential protocol. The 1
missed patient had pre-existing syringomyelia. Fifteen percent of patients with
neurological deficits of spinal cord origin had no imaging abnormality. The authors
reported that their combination protocol of clinical exam, helical CT, and MRI had a
sensitivity of 99% and a specificity of 100%. Their study provides a rational approach
to the assessment for the potential of a cervical spinal injury following trauma, and
provides Class II medical evidence. Additional supporting data is provided in Table
4.
Obtunded or Unevaluable Patient
The previous guideline author group recommended that in the obtunded or unevaluable
patient who had normal radiographic studies of the cervical spine, cervical
immobilization could be discontinued under the following conditions: normal dynamic
imaging, normal MRI within 48 hours of injury, or at the discretion of the treating
physician. These recommendations were based on Class III medical evidence provided
in the literature through 2001 that indicated that in the obtunded patient with a normal
3-view x-ray series of the cervical spine supplemented with CT (as necessary), the
incidence of a significant cervical spinal injury was less than 1%. Flexion/extension
studies could be performed under fluoroscopy safely, and could effectively rule out a
significant ligamentous injury (reported NPV of over 99%). A negative MRI within 48
hours of injury appeared to exclude the presence of a significant ligamentous injury. In
selected patients, based upon normal radiographic imaging, the mechanism of injury,
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and clinical judgment, the cervical spine could be considered stable without further
study.
Of all the clinical issues associated with the radiographic assessment of the cervical
spine, the issue of clearing the cervical spine in the obtunded or unevaluable patient
has received the most attention and remains the issue of the greatest uncertainty. The
role of CT as a replacement for plain radiographs has been the subject of active research
in this select patient population, as has the role of dynamic imaging. The increasing
use of MRI to exclude significant cervical ligamentous injury in the otherwise
unevaluable patient has also been an active area of investigation. The following section
will review the recent literature on plain films, CT, dynamic imaging, and MRI and
their application to the obtunded/unexaminable acute trauma patient.
Plain Films and CT
In 2003, Diaz et al published a prospective series of 1006 trauma patients with altered
mental status evaluated with both plain films and CT imaging scanning. One hundred
seventy-two cervical spinal injuries were identified. CT had a sensitivity of 97.4%, a
specificity of 100%, a PPV of 100%, and a NPV of 99.7%. By comparison, plain cervical
spine films had a sensitivity of 44.0%, a specificity of 100%, a PPV of 100%, and a NPV
of 93.2%. Five-view plain films failed to identify 52% of the cervical spine fractures
identified by CT imaging.
Widder et al conducted a prospective blinded study in obtunded ventilated patients
comparing the role of plain radiography and CT. In their 2004 report, the sensitivity of
plain films in detecting cervical spinal injuries was 39% compared to 100% sensitivity
of CT imaging.
In 2005, Brohi et al reported on 437 unconscious intubated patients, including 61 with
cervical spinal injuries, 31 of which were considered unstable (7%). The sensitivity of
CT was 98.1%, with a specificity of 98.8%, and a NPV of 99.7%. CT detected all unstable
injuries. In contrast, lateral cervical spine films detected only 14 unstable injuries and
had a sensitivity of 53.3%.
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Dynamic Imaging
The role of dynamic imaging in the obtunded patient remains controversial. In a recent
study, Hennessey et al in 2010 described a prospective study of consecutive trauma
admissions over a 4-year period. Included in their analysis were 402 patients who
underwent both CT and dynamic imaging of the cervical spine for suspected cervical
spinal injuries. The authors identified 1 case (0.25%) that was negative on CT imaging
yet positive on flexion and extension x-rays. Flexion and extension x-rays were used as
the comparative gold standard. The reported sensitivity of CT was 99.75%. The authors
concluded that routine flexion/extension studies were not necessary in the presence of
normal CT imaging. The use of flexion/extension as a gold standard (likely false
endpoint) and the lack of rigorously defined inclusion criteria limit the evidence
reported in this study to Class III medical evidence.
In 2006, Padayachee et al published a prospective analysis of 276 obtunded patients
who were assessed with CSR, CT, and flexion/extension studies. The authors reported
that flexion/extension studies had 94% (260/276) true negatives, 2.2% (6/276) false
positives, and 0.4% (1/276) false negative results, with no true positives. In 9 patients,
the dynamic films were deemed inadequate upon review. The authors concluded that in
this prospective cervical spine clearance protocol for unconscious traumatic brain
injury patients, flexion/extension studies under fluoroscopy failed to identify any
patient with a significant cervical injury that was not already identified either by plain
radiographs or high-definition CT.
Spiteri et al published a retrospective review of 839 trauma patients for unstable
cervical spine injuries and any cases missed by CT but identified by dynamic imaging.
The authors identified 87 patients with unstable cervical spinal injuries. CT imaging
missed 2 injuries (sensitivity 97%, specificity 100%). Flexion and extension films
identified 1 case of atlanto-occipital dislocation missed on CT (sensitivity 98.8%,
specificity 100%). No injuries or neurological worsening were attributable to dynamic
imaging. The authors concluded that dynamic imaging is safe but adds little if anything
to plain radiographs and/or CT of the cervical spine in the assessment of acute
traumatic injury.
Freedman et al studied all unconscious patients admitted over a 1-year period who
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failed to clear cognitively within 48 hours. In 2005 they reported on 123 patients who
had normal 3-view cervical radiographs who subsequently underwent passive dynamic
imaging when they were able to participate. Final injury status at follow-up served as
the gold standard. Dynamic imaging resulted in a 57% false negative rate (missed 4 of 7
injuries). None suffered an adverse neurologic outcome as a result of dynamic imaging.
The authors concluded that passive flexion and extension imaging fails to provide
adequate sensitivity for detecting occult cervical spinal injuries.
Griffiths et al retrospectively reviewed 447 trauma patients examined with flexion
and extension x-rays in evaluation for cervical spinal injuries. The outcome of interest
was worsened neurological deficit as a result of the dynamic imaging procedure. There
were no cases identified of neurological worsening following forced flexion and
extension imaging. Of 447 patients evaluated with dynamic imaging, 29 were identified
who had cervical spinal abnormalities, either fracture or ligamentous injury. In 80% of
the patients with injuries (23 of 29), no change in diagnosis was made following forced
flexion and extension studies. In 6 patients (20%), an alteration in diagnosis was made
based on positive dynamic studies. Of the 497 dynamic imaging studies, 285 (59%)
were found to be inadequate either due to inadequate motion (31%) or inadequate
visualization (40%).
In 2004, Bolinger et al reported a retrospective study of 56 consecutive comatose
head-injured patients. All patients had 3-view radiographs and CT imaging performed
and reviewed by the attending neurosurgeon and a radiologist. If these studies were felt
to be normal, flexion/extension fluoroscopic studies were performed. In only 4% of the
cases were the studies felt to be adequate to visualize the full cervical spine. Clinical
outcome served as the gold standard. Occult instability was identified in 1 patient with a
Type II odontoid fracture, and significant instability at C6-7 was identified in 1 patient
despite normal dynamic films. The authors concluded that flexion and extension
fluoroscopy was almost always inadequate for visualizing the lower cervical spine in
obtunded patients.
Davis et al evaluated the efficacy of flexion/extension studies under fluoroscopy in
obtunded patients who had normal cervical spine plain films. Over a 7-year period, 301
patients were evaluated. Ligamentous injury was identified in 2 patients (0.7%). There
were 297 true negative, 2 true positive, 1 false negative, and 1 false positive
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examinations. One patient was rendered quadriplegic by the dynamic evaluation. This
study does not provide evidence to support the routine use of dynamic fluoroscopy in
assessing the cervical spine in the obtunded patient and demonstrates the rare, but
devastating complications that may occur with dynamic imaging.
MRI
In 2010, Schoenfeld et al performed and reported a meta-analysis of 11 studies
comparing CT alone to CT plus MRI in identifying occult cervical spine injuries
following acute trauma. The authors attempted to address the question: Does adding
MRI provide useful information that alters treatment when a CT scan of the cervical
spine reveals no evidence of injury? The study included 1550 patients with a negative
cervical CT study who were subsequently imaged with MRI. Abnormalities were
detected by MRI in 182 patients (12%). Ligamentous injuries were found in 47% of the
patients and bony abnormalities in 2% of patients. Significantly, MRI identified an
injury that altered management in 96 patients (6%). Twelve patients (1%) required
surgical stabilization and 84 patients (5%) required immobilization for injuries
identified on MRI but not on CT imaging. The Q-statistic P value for heterogeneity was
0.99, supporting the validity of the study. The pooled sensitivity of MRI for detecting a
clinically significant injury was 1.00 (100%) (95% CI = 95-100). The pooled specificity
was 0.94 (94%) (95% CI = 93-95). The pooled NPV for MRI was 1.00 (100%) (95% CI =
95-100). There were no false negatives in any of the studies included in their meta-
analysis. The pooled false-positive rate was 0.06 (6%) (95% CI = 1-11). The likelihood
ratio of a clinically significant injury in the setting of a positive MRI was 17 (95% CI =
13.8-20.8). The authors advocate the use of MRI to evaluate patients who are obtunded
or unexaminable despite a negative CT study of the cervical spine. Their report provides
Class II medical evidence on this issue. The authors' meta-analysis included 6
retrospective studies. Study designs varied and had different criteria. There is no
imaging gold standard for cervical spinal instability, or for ligamentous injury;
therefore, several studies the authors included likely had false endpoints.
An earlier meta-analysis was published by Muchow et al in 2008, and included
studies by Albrecht et al, Benzel et al, D’Alise et al, Keiper et al, and Schuster et
al. The authors considered these 5 studies to provide Class I medical evidence in the
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assessment of MRI in the setting of negative plain films or CT of the cervical spine
following trauma. The authors used the following inclusion criteria: minimum 30
patients with clinically suspicious or unevaluable cervical spines, clinical follow-up as
the gold standard, data reported to allow the collection of true positives, true negatives,
false positives, and false negatives, MRI obtained within 72 hours of injury, and plain
radiographs that disclosed nothing abnormal of the cervical spine with or without a CT
scan that disclosed nothing abnormal. The pooled sensitivity, specificity, positive, and
NPV of MRI were calculated from a log odds meta-analysis. The total number of
patients in the combined studies was 464. The NPV of MRI was 100%. There were no
false negatives in any of the 5 studies included in the analysis. The pooled sensitivity of
MRI in these studies was 97.2% (95% CI 89.5, 99.3), the specificity was 98.5% (95% CI
91.8, 99.7), and the PPV was 94.2% (95% CI 75.0, 98.9). Ninety-seven injuries (20.9%)
were identified on MRI that were not diagnosed by either plain film or CT imaging. The
authors concluded that a normal MRI study in the setting of normal CSR or a normal CT
study excludes cervical spinal injury and establishes MRI as a gold standard for
excluding a significant cervical spinal injury in a clinically suspicious or unevaluable
acute trauma victim. This analysis by Muchow et al provides Class II medical evidence
in support of the role of MRI in the evaluation of the obtunded or unevaluable patient
who has negative plain radiography or CT imaging of the cervical spine. Their review
was limited by differences in the imaging protocols, the combination of negative plain
films or CT as a portion of the entry criteria, difficulty ensuring similarity of the patient
population across the 5 studies, the inclusion of a primarily pediatric study, and
extrapolating the overall results to an adult evidence-based review.
In 2010, Simon et al published a detailed analysis of 708 consecutively admitted
trauma patients and identified a subset of 91 patients who had cervical CT imaging
interpreted as negative who subsequently were evaluated with cervical MRI imaging.
The collective images of these 91 patients were independently re-evaluated by 2
fellowship-trained spine surgeons. Both surgeons agreed that the images of 76 of 91
patients (84%) were adequate to determine the potential for a cervical spinal injury.
Both agreed that the images of 7 of the 91 patients (8%) were inadequate (95% CI, 2.3-
13.1). Total Observer agreement was 91% (kappa, 0.59). The calculated sensitivity of CT
in this study was 77.3%. The specificity of CT for a cervical spinal injury was 91.5% with
a NPV of 92.0%. The addition of MRI to CT imaging improved the probability of
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identifying a significant cervical spinal injury by approximately 8%. When clinicians
skilled in the interpretation of cervical spinal imaging and the management of patients
with cervical spinal injuries were directly involved in the assessment of obtunded, high
risk patients following trauma, fewer injuries were missed compared to an initial single
read of the acute images by less experienced clinicians. This study provides Class II
medical evidence in support of the involvement of physicians trained in the diagnosis
and management of spinal injuries in the assessment of obtunded or unevaluable
patients following acute trauma in whom there is a high clinical suspicion of cervical
spinal injury yet have a normal high-quality CT imaging study.
Menaker et al offered a retrospective analysis of 213 patients who had negative CT on
a high quality 40 slice CT who had a subsequent MRI. 24% of these patients had an
abnormal MRI study (52 of 213). Fifteen (7%) underwent surgery, 23 (11%) were treated
with cervical immobilization, and 14 (6.5%) had immobilization collars removed. In
total, 8.3% of obtunded patients and 25.6% of symptomatic patients with normal CT
studies had a change in management based on MRI findings (combined 17.8%). This
2010 publication is problematic in design and provides, at best, Class III medical
evidence on the value of MRI in the acute setting following trauma, but does highlight
the increased sensitivity of MRI in detecting cervical spinal injuries.
In 2006, Stassen et al reported a retrospective analysis of 52 patients studied in a 1-
year trauma protocol utilizing CT and MRI. Thirty-one patients (60%) had both a
negative CT and MRI. The authors identified that of 44 patients with a negative CT, 13
(30%) had evidence of a potential ligamentous injury on MRI. Eight patients with
positive CT findings also had positive MRI findings. There were no missed cervical
spine injuries identified by clinical follow-up. The authors concluded that cervical CT,
when used in combination with MRI, provides an efficient method for identifying
cervical spine injuries following trauma. CT imaging alone, they added, misses a
statistically significant number of acute cervical spinal injuries. Their study provides
Class III medical evidence on this subject.
Horn et al in 2004 described a retrospective series of 6328 trauma patients that
included a subset of 314 trauma victims that were imaged with a cervical MRI for 1 of
the following indications: neurological deficit, fracture, neck pain, and/or
indeterminate clinical examination. Based on clinical follow-up, there were 65 patients
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identified with unstable cervical spinal injuries. In this group, plain films, CT, and MRI
were all abnormal. There were 143 patients who had abnormal CT or plain films. Of
these, 13 had normal MRI studies. Six of the 13 had dynamic films. All were interpreted
as normal. One hundred and sixty-six of the 314 patients had normal CT or cervical
plain films. Of these, 70 had abnormal MRI findings. Twenty-three of the 70 had
dynamic studies performed as well; they were all normal. The authors concluded that
MRI is sensitive to soft tissue image abnormalities but may add little in the detection of
a significant cervical spinal injury in the circumstance of either normal plain films or
CT study. Study design, lack of follow-up, and the lack of clear comparison groups limit
the medical evidence in their report to Class III.
In 2002, Ghanta et al published a retrospective review of 124 consecutive patients who
underwent 3-view plain films (3VPF), a full CT survey (CTS), and MRI of the cervical
spine. The study included 51 obtunded patients with normal plain films. Thirty-six of
these 51 patients had normal CT and MRI studies. The authors determined that 22% of
obtunded patients with normal cervical plain films and CTS had an abnormal MRI. Six
percent of these injuries were potentially unstable. The authors concluded that plain
films and CT imaging appear effective in detecting bony injury among obtunded
patients, but may not be sensitive enough for cervical ligamentous injuries and
significant disc herniations.
SUMMARY
Awake Asymptomatic Patient
Class I medical evidence was previously reported on this topic. The current updated
review identified additional Class I evidence supporting a Level I recommendation that
in the awake, asymptomatic patient who is without neck pain or tenderness, is
neurologically intact without an injury detracting from an accurate evaluation, and who
is able to complete a functional range of motion examination, radiographic evaluation
of the cervical spine is not recommended. The discontinuance of cervical
immobilization in this patient population is recommended.
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Awake Symptomatic Patient
Class I medical evidence was previously reported on this topic. This current updated
review identified additional Class I medical evidence that alters the previous Level I
recommendation. High-quality CT imaging of the cervical spine in the symptomatic
trauma patient has been proven to be more accurate than CSR with higher sensitivity
and specificity for injury following blunt trauma. If high-quality CT is available, 3-view
CSR are not necessary. If high quality CT is not available, a 3-view cervical spine series
(anteroposterior, lateral, and odontoid views) remains a Level I recommendation.
The question of “what to do?” if anything for the awake patient with neck pain or
tenderness and normal high-quality CT or 3-view CSR remains less clear. Only lower
level medical evidence is available to guide treatment decisions for these patients. The
current literature offers less robust medical evidence in support of the 3 following
strategies in the awake but symptomatic patient: (1) continue cervical immobilization
until asymptomatic, (2) discontinue cervical immobilization following either normal
and adequate dynamic flexion/extension radiographs, or a normal MRI study obtained
within 48 hours of injury, or (3) discontinue immobilization at the discretion of the
treating physician. Several studies favor the use of MRI (Level II) over dynamic
radiographs (Level III) in further study of these patients, but may not be feasible or
indicated in all situations.
Obtunded or Unevaluable Patient
A large number of studies have been produced since the previous guideline publication
on imaging the obtunded or unevaluable patient in order to clear the cervical spine
without the benefit of the clinical examination. The current Level I recommendation,
based on Class I medical evidence, is that high-quality CT imaging is recommended as
the initial imaging study of choice. If high-quality CT imaging is available, routine 3-
view CSR are not necessary, similar to the Level I recommendations in the other
categories. If high-quality CT is not available, a 3-view cervical spine series
(anteroposterior, lateral, and odontoid views) is recommended. The plain cervical spine
x-ray studies should be supplemented with CT (when it becomes available) if
necessary, to further define areas that are suspicious or not well-visualized on the
plain cervical x-rays.
The most controversial issue in the obtunded/unevaluable patient group is the
recommendation on the discontinuation of immobilization. The current
recommendation is that in the obtunded or unevaluable patient who has normal high-
quality CT imaging or a normal 3-view cervical spine series, 1 of the following
strategies be considered: (1) continue cervical immobilization until asymptomatic, (2)
discontinue cervical immobilization following a normal MRI study obtained within 48
hours of injury, or (3) discontinue immobilization at the discretion of the treating
physician. MRI appears to be the imaging modality of choice in this situation based on
limited and conflicting Class II and Class III medical evidence. Class III medical
evidence suggests that the routine use of dynamic imaging is of marginal benefit and is
not recommended. Class II medical evidence suggests that the decisions for the
subsequent patient management of the obtunded/unevaluable patient including
whether or not to obtain an MRI study on individual patients involve physicians trained
in the diagnosis and management of spinal injuries.
KEY ISSUES FOR FUTURE INVESTIGATION
The issue of discontinuing cervical spinal immobilization after blunt trauma remains
the area of most controversy in both the symptomatic patient with negative initial
imaging, and in the obtunded or unevaluable patient with normal cervical spinal
imaging. Numerous publications have addressed this issue and several have provided
Class II and Class III medical evidence on this topic. Although a challenge, it appears
that this issue could be addressed in a multicenter randomized trial. An appropriately
designed and conducted prospective multicenter trial has the potential to define the
optimum methodology to accurately exclude a significant cervical spinal injury in these
patients prior to discontinuing immobilization. While limited and conflicting medical
evidence suggests that MRI is recommended to further study these patients, this has
yet to be definitely proven. The question of whether there is any role for dynamic
imaging in this setting should be determined.
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ABBREVIATIONS
CCR Canadian C-Spine Rule
CCT cervical computed tomography
CSR cervical spine radiographs
EAST Eastern Association for the Surgery of Trauma
NEXUS National Emergency X-Radiography Utilization Study Group
NLC NEXUS low risk category
NPV negative predictive value
PPV positive predictive value
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